起搏器特殊起搏程序在心房颤动管理中的应用价值

The application value of special pacemaker pacing program in atrial fibrillation

目的探讨起搏器心房颤动(简称房颤)管理程序在房颤管理中的作用。方法入选因缓慢性心律失常合并阵发性房颤或心房扑动植入永久性双腔起搏器的患者,随机分为双腔起搏模式(DDDR)组、预防/抗心动过速起搏(DDDRP)组、管理心室起搏(MVP)组和兼有DDDRP和MVP组程序的DDDRP+MVP组。DDDRP、MVP和DDDRP+MVP组自术后第1个月末开启相应的房颤管理程序,包括心房优先起搏(APP)、模式转换后的超速起搏(PMOP)、抗心动过速起搏(aATP)、MVP四种程序;DDDRP组开启APP、POMP、aATP程序;MVP组只开启MVP程序;DDDRP+MVP组开启上述四种程序。术后第1、4、7个月,此后每6个月行起搏器功能程控随访,通过起搏器储存数据及临床随访资料进行分析。结果共纳入138例患者[年龄(74.0±9.2)岁;男54例],中位随访时间15个月。组内比较术后13个月,DDDR组的心室起搏比和房颤负荷均明显升高(P<0.005);DDDRP组的心房起搏比明显升高(P<0.005),MVP组的心室起搏比降低(P<0.005),但均未降低房颤负荷(P均>0.05);DDDRP+MVP组的心房起搏比明显升高(P<0.005),心室起搏比(P<0.005)和房颤负荷(P<0.005)均降低。组间比较术后13个月DDDRP组(91.5%)和DDDRP+MVP组(92%)的心房起搏比较DDDR组(63.2%)和MVP组(62.5%)均增加(P均<0.005);MVP组(0.1%)和DDDRP+MVP组(0.4%)的心室起搏比较DDDR组(3.7%)和DDDRP组(3.2%)均降低(P均<0.005);DDDRP+MVP组(0.1%)的房颤负荷低于DDDR组(2.1%,P<0.005)、DDDRP(1%,P=0.026)组和MVP组(4%,P<0.005)。DDDRP+MVP组(n=2)的心血管病住院风险较DDDR组(n=39)(HR=7.825,95%CI:1.878~32.593,P=0.005)和MVP组(n=7)(HR=5.923,95%CI:1.226~28.619,P=0.027)均降低。结论对缓慢性心律失常伴房性快速心律失常的患者,就降低房颤负荷和减少心血管病住院风险而言,DDDRP+MVP模式优于DDDR模式和单一的MVP功能。

Objective To explore the role of pacemaker atrial fibrillation(AF) management procedures in the management of AF. Methods Patients with chronic arrhythmia complicated with paroxysmal AF or atrial flapping implantation with permanent dual-chamber pacemaker were randomly divided into a double-chamber pacing pattern(DDDR) group, a preventive/anti-tachycardia pacing(DDDRP) group, a managing ventricular pacing(MVP) group and a DDDRP+MVP group with both DDDRP and MVP procedures. The DDDRP, MVP and DDDRP+MVP groups start the corresponding AF management procedures at the end of the first month after surgery, including atrial preference pacing(APP), post-mode switch overdrive pacing(POMP), atrial anti-tachycardia pacing(aATP) and MVP;DDDRP group starts APP, POMP, and aATP programs;The MVP team only starts the MVP program;The DDDRP+MVP group starts the above four programs. At the first, fourth and seventh months after the operation, pacemaker functional programmed follow-up was conducted every six months thereafter, and data stored by pacemakers and clinical follow-up data were analyzed. Results A total of 138 patients [age:(74.0±9.2)years old, Male: n= 54] were included, median follow-up time was 15 months. The intra-group differences of AF load and other indicators in each group were analyzed:Thirteen months after surgery,the ventricular pacing ratio and AF load of DDDR group were significantly increased(P<0.005).The atrial pacing ratio of DDDRP group was significantly increased(P<0.005),and that of MVP group was decreased,P<0.005,but the AF load was not reduced(P>0.05).The atrial pacing ratio of DDDRP+MVP group was significantly increased(P<0.005),and the ventricular pacing ratio(P=0.005)and atrial fibrillation load(P<0.005)were all decreased.The differences between groups of different pacing patterns on AF load and other indicators at 13 months after the operation were analyzed:The atrial pacing of DDDRP group(91.5 percent)and DDDRP+MVP group(92 percent)increased in both the DDDR(63.2 percent)and MVP groups(62.5 percent),P<0.005.The ventricular pacing of MVP group(0.1 percent)and DDDRP+MVP group(0.4 percent)were decreased in both DDDR(3.7 percent)and DDDRP(3.2 percent)groups,P<0.005`.AF load in DDDRP+MVP(0.1 percent)group was lower than that in DDDR group(2.1 percent,P<0.005),DDDRP(1 percent,P=0.026)and MVP group(4 percent,P<0.005).The hospitalization risk of cardiovascular disease in DDDRP+MVP group(n=2)was lower than that in DDDR group(n=39,HR=7.825,95%CI:1.878-32.593,P=0.005)and MVP group(n=7,HR=5.923,95%CI:1.226-28.619,P=0.027). Conclusion DDDRP+MVP model is superior to DDDR model and single MVP function in reducing AF load and risk of hospitalization for cardiovascular disease in patients with chronic arrhythmias associated with atrial tachyarrhythmias.[Chinese Journal of Cardiac Pacing and Electrophysiology,2021,35(3):220-225]